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Study flow diagram: review update
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Figure 1

Study flow diagram: review update

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'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
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Figure 2

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies

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'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study
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Figure 3

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study

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Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 1 Placement of a hydrocephalus shunt.
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Analysis 1.1

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 1 Placement of a hydrocephalus shunt.

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Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 2 Death prior to 12‐month follow‐up.
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Analysis 1.2

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 2 Death prior to 12‐month follow‐up.

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Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 3 Major disability in survivors.
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Analysis 1.3

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 3 Major disability in survivors.

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Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 4 Multiple disability in survivors.
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Analysis 1.4

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 4 Multiple disability in survivors.

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Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 5 Death or disability.
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Analysis 1.5

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 5 Death or disability.

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Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 6 Death or shunt.
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Analysis 1.6

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 6 Death or shunt.

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Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 7 Infection of CSF presurgery.
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Analysis 1.7

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 7 Infection of CSF presurgery.

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Summary of findings for the main comparison. Repeated lumbar or ventricular punctures compared to conservative treatment in newborns with intraventricular haemorrhage

Repeated lumbar or ventricular punctures compared to conservative management for infants with intraventricular haemorrhage (IVH)

Population: preterm infants less than three months of age with either: a) IVH demonstrated by ultrasound or computed tomography (CT) scan; or b) infants with IVH followed by progressive ventricular dilatation.

Settings: neonatal intensive care units.

Intervention: serial lumbar puncture, ventricular puncture, or tapping from a subcutaneous reservoir.

Comparison: conservative management.

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect (95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Risk with conservative treatment

Risk with serial lumbar or ventricular punctures

Hydrocephalus shunt

Study population

RR 0.96
(0.73 to 1.26)

233
(3 RCTs)

⊕⊕⊕⊝
moderate1

469 per 1000

450 per 1000
(342 to 591)

Death

Study population

RR 0.88
(0.53 to 1.44)

280
(4 RCTs)

⊕⊕⊝⊝
low1,2

199 per 1000

175 per 1000
(105 to 286)

Major disability in survivors

Study population

RR 0.98
(0.81 to 1.18)

141
(2 RCTs)

⊕⊕⊕⊕
high

761 per 1000

746 per 1000
(617 to 898)

Multiple disability in survivors

Study population

RR 0.90
(0.66 to 1.24)

141
(2 RCTs)

⊕⊕⊕⊕
high

537 per 1000

484 per 1000
(355 to 666)

Death or disability

Study population

RR 0.99
(0.86 to 1.14)

180
(2 RCTs)

⊕⊕⊕⊕
high

814 per 1000

806 per 1000
(700 to 928)

Death or shunt

Study population

RR 0.91
(0.75 to 1.11)

233
(3 RCTs)

⊕⊕⊕⊝
moderate1

646 per 1000

588 per 1000
(485 to 717)

Infection of CSF presurgery

Study population

RR 1.73
(0.53 to 5.67)

195
(2 RCTs)

⊕⊕⊝⊝
low2,3

43 per 1000

74 per 1000
(23 to 241)

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
Abbreviations: CI: confidence interval; CSF: cerebrospinal fluid; CT: computed tomography; IVH: intraventricular haemorrhage; RCT: randomised controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

1Downgraded by 1 as Mantovani 1980 used an alternation method for random sequence generation.
2Downgraded by 1 due to imprecision, which is present because the width of the CI is consistent with both important benefit and harm.
3Downgraded by 1 due to inconsistency between studies. Dykes 1989 reported no cases of CSF infection. Ventriculomegaly 1990 reported infection in 10/157 cases.

Figuras y tablas -
Summary of findings for the main comparison. Repeated lumbar or ventricular punctures compared to conservative treatment in newborns with intraventricular haemorrhage
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Comparison 1. Lumbar punctures or ventricular punctures versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Placement of a hydrocephalus shunt Show forest plot

3

233

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.73, 1.26]

2 Death prior to 12‐month follow‐up Show forest plot

4

280

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.53, 1.44]

3 Major disability in survivors Show forest plot

2

141

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.81, 1.18]

4 Multiple disability in survivors Show forest plot

2

141

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.66, 1.24]

5 Death or disability Show forest plot

2

180

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.86, 1.14]

6 Death or shunt Show forest plot

3

233

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.75, 1.11]

7 Infection of CSF presurgery Show forest plot

2

195

Risk Ratio (M‐H, Fixed, 95% CI)

1.73 [0.53, 5.67]
Figuras y tablas -
Comparison 1. Lumbar punctures or ventricular punctures versus control
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